Healthcare Provider Details

I. General information

NPI: 1073117685
Provider Name (Legal Business Name): OLIVIA LEE GRAY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/24/2020
Last Update Date: 06/26/2023
Certification Date: 06/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1006 COMMERCE ST
WELLSBURG WV
26070-1567
US

IV. Provider business mailing address

1006 COMMERCE ST
WELLSBURG WV
26070-1567
US

V. Phone/Fax

Practice location:
  • Phone: 304-737-4435
  • Fax:
Mailing address:
  • Phone: 304-737-4435
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2530
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: